Hellp

I start rounds right across from labor and delivery. A long man operated on two days ago for hydrocele and hernia is sent home after being advised to quit drinking as his alcoholism became evident during his difficult Ketamine anesthesia. A pregnant woman who came in yesterday with a hemoglobin of 4.3 sits with a blood bag attached to her arm with the plasma still inside. She has got two 450ml bags of whole blood and needs more but no family members can be found. The baby with the ileostomy is sleeping comfortably beside her mother. The ostomy that herniated out last night is back in place and the midline incision appears to be healing well.



The little girl in the old maintenance closet turned into isolation ward is sitting up half naked eating some porridge. Six days of Chloramphenicol with a single dose of Ceftriaxone have done wonders to transform her meningitis coma into a hope of full recovery.



Moving past the nurses station and the chaplain's office I greet the Fulani nomad woman with a long, gunnysack sewn up wound across her chest into her armpit where her tumor filled breast and lymphnodes used to be. The deep cavity left by the removed lymphnodes has become infected and is being dressed with diluted bleach. She wants to go back to the bush where she can drink milk from her own cows. She just doesn't like the food available here in Bere. We finally convince her son to keep her here.



Two men operated on yesterday for large inguinal scrotal hernias grace the next two beds. I order there IVs out and for them to get up and ambulate.



Beside them is a woman who's life we barely saved three months ago. She had been in labor for 3 days and came in with a dead and decomposing baby stuck in her small pelvis. A symphysiotomy brought the baby out quickly but the gangrenous flesh had to be debrided several times and her vagina packed for weeks with diluted bleach soaked compresses and heavy doses of antibiotics. As a result, she developed an enormous vesico-vaginal fistula and a scarred down vaginal vault and cervix. Three days ago I attempted a vaginal repair with not much success. That evening I was awoken by a sense of God's presence and an idea to operated on her the next day which I did opening up her bladder from the abdominal side and inserting a ureteral catheter into her right ureter to drain the urine out the abdominal wall. Her left ureter appeared scarred down as the catheter wouldn't pass. I then closed up the defect from on top and left the a foley catheter in the urethra and the uretral catheter coming out her lower abdomen. 



Today there is clear urine out of the right ureteral catheter and bloody urine out of the bladder drain meaning that maybe her left ureter is working after all. More importantly, she has no vaginal leakage.



An emaciated Arab lies across the way. I saw him at 4:30 this morning with almost no blood pressure and a raging fever. He responded to IV fluids and IV quinine. I suspect him of AIDS and add broad spectrum antibiotics. His HIV status is confirmed later and he dies in the early afternoon.



Meanwhile I move on to the middle aged woman who had a hysterectomy yesterday for fibromas. She is well. Next to her is a woman who has had her knees permanently bent since the age of 12 due to burn contractures until January when Dr. Bond released her right leg. I released her left leg in February and the wounds are healing well and she can almost straighten both legs now.



First bed on the left in the men's ward is a man with an abscess deep in his thigh to the side of his hip joint and back into his gluteus. The drain is still working and the swelling and pain have gone down. His neighbor is another hernia that is sent home. To the right is a man with gangrene of the scrotum debrided radically 6 days ago who got malaria and had a hemoglobin of 4.7 found yesterday who is still waiting for other family members to come since no one has the right blood type. His wound is much better and he is sitting up comfortably.



Missing from their mosquito net covered beds are the two miracle burn kids who are almost healed without skin grafts. In fact, little Bai has become Sarah's little adopted kid and walks around with her squirting patients with syringes full of water and sitting in her lap for morning worship. The older girl is healing well but is depressed and doesn't want to get up.



The young man who was stabbed clear through the front of his shin between his two leg bones into the back of his calf severing his large vein and puncturing his artery is doing better today. I thought he had an abscess so took him to the OR by myself only to find myself removing massive clumps of blood clot releasing a pent up surge of raging blood. Since it was coming from behind the tibia there was no way to compress it. I ran and pulled up a used suction tubing from a basin and quickly tied it around his leg above the knee to stop the bleeding before calling in help, opening up his calf, dissecting down to the vessels, suturing the hole in the artery and tying off both ends of the vein. He know complains of foot pain. I prescribe Ibuprofen and paracetamol.



His neighbor is the man who came back a month after refusing surgery for an open tibia fracture with his leg completely infected, swollen, edematous and spilling out pus from a non-union broken bone. We had to radically remove the front of the tibia and pierce his tibia with four Steinmann pins attached to some PVC pipe to act as an external fixator. The wound still smells but is much better and fortunately the pus around the pins is starting to dry up.



I tell Simeon and Abel to prepare the woman for the hysterectomy, do the spinal anesthesia and call me. Meanwhile I round on a pediatric ward filled with Malaria kids, most of whom are recovering and can be sent home.

I do the fastest hysterectomy of my life and go out to do a couple of ultrasounds while the OR crew prepares the 4 year old boy with bladder stones. As I approach my office a well-dressed woman greets me with her cute little daughter. She's about 4 years old with a spotless, frilly baby blue dress and newly braided hair and a sweet smile as she profers me her hand in a shy greeting.

"Do you recognize her? You delivered her by c-section in 2004 when you first came here."

I don't remember, but smile and nod as I go into my office with warmth in my heart.

I finish the first ultrasound and Sarah peeps in the door.

"You better see this patient in the ER."

"You mean now, is it urgent?"

"Yes, this woman is crashing!"

I rush out across the campus under the mango trees to the ER.

A woman lies in an army stretcher barely breathing, swollen eyes shut and gurgling through a weak respiratroy effort. She is obviously pregnant.

"Augustin, Job, Prudence! Grab her and bring her directly to the OR!"

We dump her directly onto the OR table and I prepare to intubate her as Abel quickly finds an IV. She starts to bleed as I search for her swollen vocal cords and finally slip the ET tube through with help from Simeon's cricoid pressure. I call for another IV and a glucometer and hemoglobin measurement. Her body is burning up so we have Ringer's Lactate running wide open on her right arm and IV quinine on her left. Simeon has put in an NG tube releasing some nasty gastric contents which spill onto the floor from the open urine bag attached to the end. She starts to gurgle blood from her nose and mouth in frothy spurts. Simeon suctions. Her glucose comes back way low and we trade Ringers' for Dextrose.

I go get the ultrasound from my office and confirm a normal fetal heartbeat, cephalic presentation and 33 weeks estimated gestational age. Her blood pressure is initially normal but suddenly sky rockets and stays high. We do a urine dipstick which is highly positive for protein suggesting the diagnosis of pre-eclampsia. With her enlarged liver and uncontroallable bleeding I also suspect HELLP syndrome. The only thing is to deliver the baby.



A quick, uneventful c-section brings a small but well-developed boy into the world with great tone and grimace. I pass him off to Hortance and sew up the uterus, fascia and skin. The woman is still doing poorly with heart rate over 150/minute and high blood pressure and low O2 saturations. Blood is everywhere as she continues to spray bloody foam all over. I don't hear a cry from the baby but Hortance has said he was breathing. I go over to look and find him pale, limp, with no respiratory effort and a slow heartbeat. I am furious and try desperately to do CPR and bring him back but it's too late.

We leave the woman in the OR on a gurney where we can monitor and suction her. We get two bags of whole blood running hoping the platelets will help the bleeding. We operate on the 4 year old pulling out two marble sized stones out of him and closing him up uneventfully. The woman is still breathing but sating in the low 80's. The watery blood continues to well up out of her nostrils and gurgle out her oral airway that has replaced her ET tube since we don't have a ventilator.

A quick inguinal hernia on a woman is done quickly and finally we decide to just wheel the woman out to the wards since the family is getting anxious and people don't understand when someone dies in the OR; they tend to think you killed them.

Gasps of fear flutter up from the crowd of relatives gathered outside surgery as we wheel the blood specked woman and gurney out to the wards. We drop her in a bed, tell the husband to wipe up the blood as it spouts out of the mouth and nose, write orders for IV fluids and IV quinine and leave her in God's hands.